- Olivier Fontaine, medical officer, child and adolescent health and development1,
- Paul Garner, professor of community health email@example.com,
- M K Bhan, secretary for biotechnology3
- 1World Health Organization, Geneva, Switzerland
- 2Liverpool School of Tropical Medicine, Liverpool L3 5QA
- 3Ministry of Science and Technology, Government of India, New Delhi, India
Each day at the height of the monsoon season in the early 1970s 6000 starving refugees from the India-Pakistan war poured into refugee camps: a cholera epidemic was inevitable. The sheer volume of patients meant that the government of India, the state government of West Bengal, and non-governmental agencies simply could not provide enough intravenous saline solution or staff to administer it, and 30% of patients died within a few days.
One witness to the tragedy was Dilip Mahalanabis, who, as a member of staff of the Johns Hopkins Center for Medical Research and Training in Calcutta, had helped develop a new oral rehydration solution to replace the water and electrolytes lost through vomiting and diarrhoea. Oral rehydration therapy had been discovered a few years earlier simultaneously in Kolkata (Calcutta) by N F Pierce and in Dhaka by N Hirschhorn but had only ever been used by paediatric specialists in tertiary referral hospitals. Mahalanabis seized on the idea that the therapy might work in this dire catastrophic context too. His team weighed out the ingredients in Kolkata, tipped them into plastic bags with simple instructions, sealed them with a hot iron, and rushed them to the camps. Relatives, parents, and health staff urged patients to drink large volumes of solution in the early stages of their illness. Over eight weeks mortality fell to less than 1%.
An amazing discovery
However, the medical establishment was sceptical about these dramatic results and rejected Mahalanabis's paper reporting them. It took a visit from Dhiman Barua, a cholera specialist from the World Health Organization, for the enormity of the discovery to be realised. He was amazed by what he saw: basic health orderlies, parents, and relatives all treating cholera successfully with just oral rehydration solution. Barua understood then that not only could the solution treat cholera but it also had the potential to completely revolutionise the community management of diarrhoea in children.
His vision led to the creation in 1978 of WHO's diarrhoeal disease control programme, which has popularised this treatment throughout the world. It is simple and it works—and a systematic review in the Cochrane Library has shown that even in developed countries there are no clinically important differences in effectiveness and safety between oral and intravenous fluid replacement.1 In 1970 Mahalanabis had to prepare his own packets; now close to 500 drug companies produce oral rehydration solutions, the formulation of which was recently improved for greater effectiveness.
In the 1980s nearly five million children under 5 years old died each year from diarrhoea. In 2000 this figure had dropped to 1.8 million. Oral rehydration is central to the package of measures that has helped ensure this fall in mortality. At the beginning of an episode of diarrhoea the child is given increasing amounts of fluid prepared at home, to prevent dehydration. If the child is already dehydrated, oral rehydration solution is given at home or in healthcare centres, and if this fails intravenous fluid replacement is given. Feeding and breast feeding continue during the illness and are increased after the episode, and antibiotics are used only when appropriate, such as when the child has bloody diarrhoea or shigellosis.
Diarrhoea as a cause of death in young children has fallen from 33% of deaths to 18% since the 1980s, and this decline is largely responsible for the fall in total mortality in young children over this period. David Sack, director of the International Centre for Diarrhoeal Disease Research in Bangladesh, said, “To save the life of a person with diarrhoea is probably the cheapest health intervention you can think of.”
Fifty million children's lives saved
Without oral rehydration treatment, and with a roughly static incidence of three episodes of diarrhoea every year, children in poor countries are faced with a potentially life threatening infection every four months; and in families of four children, every month of the year the parents would be likely to have a child with an infection that has the potential to kill. With the proper use of oral rehydration therapy these risks become almost zero. Because more than 50 million children's lives have been saved over the last 25 years, thanks to oral rehydration, a large chunk of the adult population in developing countries is alive today.
What does the future hold? Vaccines against rotavirus could be important but are currently expensive. Oral rehydration solutions have been improved since the early days: the formula was adjusted after a Cochrane Library systematic review in 2001 showed that a less concentrated solution had better outcomes.2 And the treatment strategy now includes giving zinc for a couple of weeks, as this not only reduces the severity and duration of the episode but also protects the child from further episodes in the following 2-3 months.
These improvements will make management of diarrhoea even more successful. But the great challenge is how to reach all children who are still suffering and dying from diarrhoea and who belong to the poorest section of the population. It is a tragedy that 1.8 million preventable deaths from diarrhoea occur every year just because children do not have access to this cheap, easily prepared solution. There is still a desperate need worldwide to promote and distribute this life saving intervention and help parents use it when their child becomes sick with diarrhoea.
Competing interests: None declared.
Publication of this online supplement is made possible by an educational grant from AstraZeneca